Your plan for better healthSM1

Prior approval and quantity limitations

Select the plan for which you would like to review prior approval and quantity limitation information:

Blue Medicare HMO, Blue Medicare PPO and Blue Medicare Rx

Prior authorization and nonformulary requests

Prior authorization and nonformulary requests require members to meet certain clinical criteria prior to a drug being covered.

For prior authorization and nonformulary requests, the member or the member's prescribing physician may contact Blue Medicare HMO, Blue Medicare PPO and Blue Medicare Rx. A physician's supporting statement is required for all requests before the prescription can be approved for payment. Physicians may contact the plan by calling Blue Medicare HMO or Blue Medicare PPO at 1-877-494-7647 or Blue Medicare Rx at 1-888-298-7552 or using the applicable fax request form (see below) to request an exception. Please see the member's formulary for detailed information regarding covered drugs and drugs requiring prior approval. Download and submit the following forms to request prior approval for a nonformulary drug request.

  • Blue Medicare HMO / Blue Medicare PPO Request Form
  • Blue Medicare Rx Request Form

Nonformulary requests

Should list drug alternatives tried by member for the same condition and the clinical reason these drugs have not been as effective as the drug being requested.

Drugs that require prior approval

Drugs that can be covered under Part B, Blue Medicare HMO, Blue Medicare PPO and Blue Medicare Rx. Please see the member's formulary for a list of drugs that require prior authorization. Drugs that are currently authorized by law as covered under Part B will remain covered under Part B and should be billed to the Part B payer as before. For information about and a listing of drugs covered under Part B, visit the Cigna Government Services Web Site. This site includes access to DME MAC Jurisdiction C Local Coverage Determinations. You may also visit the CMS Web site for additional information regarding Part B and Part D coverage.

Below is a list of medications/drug classes that can be covered under Part B, Blue Medicare HMO, Blue Medicare PPO and Blue Medicare Rx. Coverage is dependent upon indication and/or administration:

Drug/Drug Class Covered Under Part B for the following indications
(Summary provided: See DMERC policies and CMS guidance for specific criteria):
Nebulized gentamicin
Cystic fibrosis
Nebulized tobramycin (TOBI) Cystic fibrosis
Nebulized pentamidine (Nebupent) HIV
Complications of organ transplant
Inhalation drugs Certain inhalation drugs are generally covered when used with a nebulizer in the home. (SNF and others cannot be considered "home" (see CMS guidance)
Immunosuppressive drugs For a beneficiary who has received a Medicare-covered organ transplant
Oral anti-emetics drugs Oral anti-nausea drugs used as part of an anticancer chemotherapeutic regimen as a full therapeutic replacement for an IV anti-emetic drug within 48 hours of chemo administration.
Hepatitis B vaccine The vaccine is administered to a beneficiary who is at high or intermediate risk of contracting hepatitis B.
Erythropoietin For the treatment of anemia for persons with chronic renal failure who are on dialysis.
Intravenous immune globulin (IVIG) Provided in the home for a diagnosis of primary immune deficiency disease
Parenteral nutrition For patients who cannot absorb nutrition through their intestinal tract (nonfunctioning digestive tract)
Infusable drugs Infused using an implantable pump or infused using an external pump in the home (SNF and others cannot be considered "home")
Osteoporosis Provided by a home health agency to females meeting coverage criteria for home health benefit and criteria found in the MA Benefit Policy Manual, Section 50.4.3

If these medications are not eligible for coverage under Part B, they will be covered under Part D with prior approval by the plan. Examples of drugs always covered under Part B:

  • Pneumococcal vaccine
  • Influenza vaccine
  • Antigens
  • Blood clotting factors

Quantity limitations1

The Quantity Limitations program sets quantity limits on a small number of medications. Blue Medicare HMO, Blue Medicare PPO and Blue Medicare Rx will cover the drug up to the designated quantity. If the prescribing doctor feels it is medically necessary to exceed the set limit, they must get prior approval before the higher quantity can be covered. Physicians can call Blue Medicare HMO at 1-888-310-4110, Blue Medicare PPO at 1-877-494-7647, or Blue Medicare Rx at 1-888-247-4142. After normal business hours messages can be left on the Part D After Hours Exception voice mail.

Quantity Limitations are designed to identify the excessive use of drugs which may be dangerous in large quantities and to highlight the potential need for a different type of treatment.

For patients who may require dosages in excess of the quantity limit (QL), please download and submit the appropriate fax request form listed below.

The following are lists of drugs with quantity limits for Blue Medicare HMO/PPO and Blue Medicare Rx.

1 * All services are subject to the allowed amount charge. When using out-of-network providers, any amount charged over the allowed amount may be your responsibility.

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